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Bt4p SH SHIP# 234545330 HIS III Milli III III I I <br /> Please pant or type. Form Approved.OMB Na-205Dd7039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 'r XR@00081 c$5 [2. g 1 of 31F�y I nse�; 4.Manffest Tracldn Number <br /> WASTE MANIFEST �[���5 o n 7 7$O 9 3 0 SKS <br /> 5.�`�PV_�-��I� EMS, INC. Gene�Tpa�3`F� t a 9YEAllressl I NCr. <br /> Pia BOX 555 5050 SALIDA BLVD <br /> SAL I DA CA 95366 <br /> Generator's Phoria <br /> X09-545-1011 SALI�R CA 95,368 <br /> '-VF&V&WttW SYSTEMS INC U.S.EPA ID Number T k R0000B l 205 <br /> 7.Transporter 2 Company Name U-S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY-KLEEN OF CALIFORNIA U-S.EPA ID Number <br /> 6880 SMITH AVE. <br /> NEWARK CA '34560 <br /> 510-795-440f CAD980887418 <br /> Fadlitys Phone: <br /> ga- 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if arry)) 13-Waste Codes <br /> No. Type Quantity Wf.Nol. <br /> 1. NON--RCRA HAZARDOUS WASTE, LIOUID TT G X21 <br /> o (USED CILi <br /> Z 2. <br /> ui <br /> C9 <br /> 3, <br /> 4. <br /> 14.Special Handling Insbuctions and Additional Information TSD:EVG SAL CSG.- <br /> 24H <br /> SG:24H EMERGENCY#800-468-1750-CHISK/TFI-CDntraet retained by generator confers a enoy authority <br /> on initial transporter to add or substitute additional transporters ort enera�or' s behalf. - <br /> 1& <br /> ehalf.15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and aowratdy described above by the proper snipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.ff export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment DDnforrn to the terms of the attached EPAAcknowledgment of Consent. <br /> I oar*that the waste minimization statement identified in 40 CFR 282.27(a)(d I am a large quantity generator)or(b)(if I am a small quentity generator)is true- <br /> Generatoees Printed/Typed Name Signature Month Day Year <br /> r,�t' 0,OA Al � . <br /> J 16.international Shipments <br /> I— ❑Import to U.S. ❑Export from U.S. Port of entrylerdt: <br /> x Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Admowledgment of Receipt of Materials <br /> Transporter 1 PrirdadlTypad Name Signature Month Day Year <br /> 19 115 IZI2 Transporter 2 Prirtedffyped Name Signature MmM DayYear <br /> F <br /> 18.Discrepancy <br /> 18a.Dlsammncy indication Space ❑ ou"tity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b-Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ri Faddy's Phone: <br /> IBe,Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> a <br /> N19,Hazardous Waste Report Managementfdethoel Codes(Le-,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> G 1. 35 2. 3, 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials Dovered by the manifest exce as noted in Item 1 <br /> PrinVKAved Name Month Day Year <br /> E,qF 41-�721{� J-�7] Previous editions are obsolete. 1GNATED FACILITY TO FAA's e-MANIFEST SYSTEM <br />